Summary Report for FSPSAs Initiated During the Report Period Center: 54
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 953 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 12 12 10.600001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 12 10.600001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 66 77 71.261904 $3456.2000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 0.922222 $51.7400 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.427778 $10.1300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.427778 $6.2800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 6.377778 $140.7600 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.427778 $3.7700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.427778 $12.3700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.427778 $64.3700 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.427778 $5.9100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.427778 $30.0400 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.261111 $22.7000 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 4.650000 $210.7400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.427778 $49.5400 $115.8200
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Subtotal (Total Children Is Unduplicated) 77 103 88.895239 $4064.5400 $45.7200
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 0.961112 $40.7600 $42.4100
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.011111 $42.8800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 24.177777 $120888.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.222222 $51.4700 $231.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 202 244 183.180955 $9159.0700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 11 9.011112 $450.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 35 36 27.073811 $1353.7000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 75 171.711907 $8585.6100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 -2.550000 $-63.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 74 51.685710 $2584.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 120 129 86.048405 $4302.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 -0.549999 $-13.7500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.555556 $38.8900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 5.466667 $273.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 62 66 366.523812 $18326.1900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 5.000000 $250.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 65 125 374.800791 $4497.6100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 15 82.684127 $5949.9600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.466667 $177.5000 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 4.717460 $339.4700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 7 7 14.366666 $1033.8200 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.427778 $1114.8900 $459.2200
SENS -V5264 EARMOLD 2 2 1.761111 $31.9300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 94.419048 $6794.4000 $71.9600
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Subtotal (Total Children Is Unduplicated) 390 838 1509.173806 $186234.6800 $123.4000
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Total 953 1608.669046 $190299.2200 $118.3000
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Number of Children (Unduplicated) With at Least One Authorization 407